Fillable DENTAL RENEWAL APP

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DENTAL RENEWAL APP

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The DENTAL RENEWAL APP form is 7 pages long and contains:

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  • 105 check-boxes
  • 269 other fields

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Page 1 of 7
DENTISTS & ORAL SURGEONS RENEWAL APPLICATION
Instructions to the Applicant – please complete this application in ink and answer all questions completely. Attach extra
sheets as necessary should you run out of space provided. An incomplete or illegible application cannot be processed.
Completion of this application neither binds coverage nor guarantees that a policy will be issued.
Provide a fully completed application, signed and dated by the owner, partner, or officer not earlier than 45 days before
the renewal effective date of coverage.
If a question is not applicable, then state “N/A”.
The following information must be submitted with the completed application:
- Copy of your Curriculum Vitae and letterhead IF CHANGED IN THE PAST 12 MONTHS.
- Current loss runs from a prior insurance company, IF ANY OF THE FOLLOWING APPLIES:
- There was an open claim, suit or incident pending with a prior insurance company;
- An Extended Reporting Period (ERP) Endorsement was purchased from a prior insurance
carrier within the past 5 years;
- Coverage was written on an occurrence basis by the insurance company within the past 5
years.
- A Claim Supplemental Form or comprehensive narrative on your letterhead must be
completed for each claim resolved/closed or a new claim made, incident surfacing and/or
suit brought against you IN THE PAST 12 MONTHS that has not already been reported to
Kinsale Insurance Company.
PERSONAL INFORMATION
Applicant’s Name and Professional Designation: ________________________________________________________
__
Business Entity Name:_______________________________________________________________________________
Practice Address: ___________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
Mailing Address: ___________________________________________________________________________________
STREET CITY COUNTY STATE ZIP
Provide the following information for all states in which you are license to practice:
State
% of Practice
License#
Active
Inactive
Temporary
Pending
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 7
Provide the following information for all states in which you are license to practice:
State
% of Practice
License#
Active
Inactive
Temporary
Pending
PRACTICE SPECIALTY
1. Current Practice Specialty: % of Practice:
Subspecialty: % of Practice:
2. Do you limit your practice to the above Specialty and/or Sub-Specialty? YES NO
If NO, please explain:
3. Have you added or discontinued procedures which are considered to be outside of, or not YES NO
usual to the above practice specialty, or are experimental in nature within the past year, or
do you anticipate doing so in the near future? If YES, please list procedures/services and note dates of change(s):
4. Have you changed your dental specialty within the past year or do you anticipate doing YES NO
so in the near future? If YES, please explain:
5. Indicate number of CE hours you have completed in past two years:
OFFICE STAFF
6. Do you employ, contract with, or supervise any dentists? YES NO
If yes, provide the number and attach COI for each:______
7. Do you share office space or have an expense sharing arrangement with any other dentist YES NO
other than those named above?
If yes, provide the number and attach COI for each:______
8. Do you employ, contract with or supervise any non-dental health care extenders? YES NO
If yes, complete the table below
Type
#Employed
# Contracted
Insured?
Dental Assistant
Yes No
Dental Technician
Yes No
Hygienists
Yes No
Physician*
Yes No
Physician Assistant
Yes No
Surgeon Assistant
Yes No
CRNA
Yes No
Nurse (RN, LPN, LVN)
Yes No
X-Ray Technician
Yes No
Other
Yes No
* If coverage is desired, please complete a separate application for each
Risk Management Contact Name:
Risk Management Contact E-mail:
Page 3 of 7
SPECIFICS OF PRACTICE/PROCEDURES
9. Average Weekly Practice Hours:
___________
10. Average Weekly Patient Encounters:
___________
11. Do you use analgesia, sedation, or anesthesia on patients? YES NO
If you perform any of the following types of anesthesia, then complete the table; otherwise enter “N/A”
Inhalation
Conscious
Oral
Conscious
Parenteral
Conscious
Parenteral Deep
Sedation
General
Anesthesia
% of patients under age 18
Drugs used
Office, Surgi-Center or
Hospital Setting
Administered by:
12. Provide the approximate percentage of your practice in the following:
Bone Grafting ____% Microneurosurgical Procedures ____%
Cosmetic Dentistry Oral Pathology ____%
Bonding ____% Oral Radiology ____%
Enamel Shaping ____% Orthodontics ____%
Full Mouth Restoration ____% Orthognathic Procedures ____%
Veneers ____% Pediatric Dentistry ____%
Whitening with Lasers ____% Periodontics ____%
Other Procedures ____% Prosthodontics ____%
____________________________ Prosthetics
Non-Dental Cosmetic Procedures (Botox, Fixed ____%
Collagen, fillers, etc)___________________ Removable ____%
____________________ ____% Sleep Apnea ____%
Endodontics Surgery ____%
Single Rooted ____% Therapy ____%
Multi Rooted ____% Surgery
Sargenti Root Canal Method ____% Facial – Elective Cosmetic ____%
General Dentistry Head and Neck ____%
Extractions of Impacted Teeth ____% Oral/Maxillofacial ____%
Oral Surgery__________________________ Outside oral/maxillofacial region
_________________________ ____% ____________________ ____%
Root Canal ____% TMJ
Simple Extractions Only ____% Non-surgical ____%
Implants Surgical ____%
Restoration ____% Other _______________________ ____%
Placement ____% Other_______________________ ____%
TOTAL 100%
13. If you have performed any implant procedures within the last year, then answer the following:
I have not performed any implant procedures within the last year: _____(initial)
1. Osseointegration only _____ # procedures
2. Endosteal - Ramus Frame _____# procedures
3. Endosteal - Other _____# procedures
4. Subperiosteal (above bone but beneath gum) _____# procedures
5. Transosseus (penetrate entire jaw) _____# procedures
Page 4 of 7
6. Other ________________________________________ _____# procedures
7. Do you perform sinus lifts or other surgical procedure
in conjunction with implant procedures? ____Yes ____No
14. Check all Procedures/Treatments that you perform and indicate where:
Procedure Office Hospital Other
Biopsies _____ _____ _____
Blepharoplasty _____ _____ _____
Cheek Implant _____ _____ _____
Chin Surgery _____ _____ _____
Cleft Lip or Palate Surgery _____ _____ _____
Cosmetic Procedures
Botox Injection _____ _____ _____
Chemical Peels _____ _____ _____
Chemobrasion _____ _____ _____
Collagen Injection _____ _____ _____
Dermabrasion _____ _____ _____
Face Lift _____ _____ _____
Laser Skin Resurfacing _____ _____ _____
Other Laser Procedure (specify:____________) _____ _____ _____
Lippodissolve _____ _____ _____
Microdermabrasion _____ _____ _____
Silicone Injection _____ _____ _____
Other:_______________________________ _____ _____ _____
Liposuction _____ _____ _____
Oral/Maxillofacial Surgery _____ _____ _____
Rhinoplasty _____ _____ _____
Sargenti root canal method _____ _____ _____
Sinus Lift _____ _____ _____
TMJ Surgery _____ _____ _____
Uvulopalatoplasty _____ _____ _____
Other:_______________________________ _____ _____ _____
Other:_______________________________ _____ _____ _____
I do not perform any of the above procedures/treatments Initial: _____
15. In the past 12 months:
a. Has any State/Dental Board refused you a dental license?
b. Has any State/Dental Board restricted, suspended or revoked your dental license?
c. Has any State/Dental Board imposed a fine or any other obligation?
d. Has any State/Dental Board issued a letter of guidance or public reprimand?
e. Have you voluntarily surrendered a medical license?
f. Has any State/Dental Board placed you on probation or restricted your practice?
g. Is your dental license currently under investigation for any reason in any state?
h. Has your Narcotics/DEA license been surrendered/refused/suspended/revoked
(voluntarily or otherwise)?
i. Has there been any professional conduct or fee complaint filed against you with any
Specialty, National, State or County Dental Society, other Professional Association or any
licensing or regulatory authority?
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
If YES to any of the above, describe the circumstances, outcome, dates on Page 5 and attach copies of any relevant
documents.
Page 5 of 7
SUPPLEMENTAL INFORMATION
Use this page to as needed to address questions referenced within the application or to provide information
you deem pertinent to our review of your application
16. In the past 12 months:
a. Have you become American Board Certified?
b. Has your Board Certification or membership in any dental association/society been
refused, suspended, revoked or voluntarily surrendered?
YES NO
YES NO
17. In the past 12 months:
a. Have you been evaluated, treated, or recommended for treatment of alcohol, narcotics, or
any other substance abuse, sexual addiction, or mental illness?
b. Have you been diagnosed with, or treated for, a chronic physical illness and/or disability?
c. Have you become aware of any physical illness, mental illness and/or disability which
affects, or could affect, your ability to practice dentistry now or anytime in the future?
YES NO
YES NO
YES NO
IF YES to any of the above, describe circumstances, outcome, dates and attach copies of any relevant documents (including a letter
from your treating physician addressing your state of health and whether such condition could adversely affect your ability to practice
medicine).
18. IN THE PAST 12 MONTHS, have you been charged with or convicted of a felony or YES NO
misdemeanor for anything other than a minor traffic violation? IF YES, describe circumstances,
outcome, dates and attach any relevant documents.
19. IN THE PAST 12 MONTHS, have your hospital privileges been suspended, denied, revoked, YES NO
restricted, or otherwise sanctioned? IF YES, describe circumstances, outcome, dates and attach any
relevant documents. ________
20. Are you aware of any request for dental records by a patient or his/her attorney which might
result in a claim? If YES, please complete Supplemental Claims Information on Page 7.
YES NO
21. Are you aware of any prior professional liability carrier refusing coverage for, or declining to
accept a report of a specific act, omission, or circumstance involving particular and specific
professional services that may result in a claim, threat of claim, letter of intent, adverse result
notice, or attorney contact?
If YES, describe circumstances, outcome, dates and attach any relevant
documents.
YES NO
22. Have all circumstances that might reasonably lead to a claim or suit, even if you believe them
to be without merit, been reported to your current or prior professional liability company?
Indicate N/A if you are not aware of any such circumstances. If yes, how many? ___________
Please complete a supplemental claims form for each.
YES NO
N/A
Page 6 of 7
STATEMENT OF NO KNOWN CLAIMS or CIRCUMSTANCES
• I have no known losses or claims that have not been reported to my prior insurance carrier or any other source
from which payment might be made;
• I have no knowledge of acts, omissions or circumstances that relate to a professional service which could
reasonably result in a claim, that has not been reported to a prior insurance carrier;
• I have no knowledge of any request for medical records by a patient or their attorney which might result in a
claim;
• I have no knowledge or information relating to service or services on a Board which might result in a claim; and
• I have no knowledge of any prior professional liability carrier refusing coverage for, or declining to accept a
report of a specific act, omission or circumstance involving particular and specific professional services that may
result in a claim, threat of claim, letter of intent, adverse result, or attorney contact.
My signature below confirms the above statements
CONSENT, WARRANTY, REPRESENTATIONS and ACKNOWLEDGMENT of UNDERSTANDING FRAUD WARNING
Any person who knowingly, and with the intent to defraud any insurance company or other person, includes any false or
misleading information in an application for insurance or statement of claim commits a fraudulent insurance act, which
is a crime and subjects the person to criminal and civil penalties and denial of insurance benefits.
The applicant declares that the information contained herein is accurate and that no material facts have been
suppressed. The applicant understands and acknowledges that the information contained in the application is deemed
material and that any policy issued by the Company is done so in reliance upon the truth of the applicant’s
representations. The applicant understands that incorrect information could void coverage.
Signature: ___________________________________________________________ Date:_____________________
Printed Name:________________________________________________________
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Page 7 of 7
SUPPLEMENTAL CLAIMS INFORMATION
If reporting more than one claim, then please photocopy this form and complete a separate form for each. Attach additional
sheets if necessary for adequate explanation. All questions must be answered or marked Not Applicable (N/A), and each sheet
must be signed.
Name of Patient: Age:______ Sex:_______
Date reported to insurance company:
Name of insurance company:
Date of incident and your treatment:
Allegations:
Additional Defendants:
What is the present condition of the patient?
Status of Claim
___Suit threatened, no action taken Court outcome in your favor: Unresolved/Open
___Suit filed but dropped by claimant ___Jury verdict ___Awaiting mediation
___Summary judgment in your favor ___Directed verdict ___Awaiting court action
___Suit settled out of court Court outcome in favor of plaintiff: Reserve amount:
a. Date claim paid: ___________ ___Jury verdict $__________________
b. Amount paid: $____________ ___Directed verdict
c. Did you want to settle? Yes No Amount of loss payment: $_____________________
Name and address of the attorney assigned to your case:
To your knowledge, was any settlement paid by another party involved Yes No
(i.e., your P.A., P.C., partners, employees, etc.)?
Explain in detail what action(s) you have taken to prevent recurrence of this type of claim:
Signature: Date:
Printed Name:
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Completed 2 July 2020

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